For me, orthodontic treatment starts with the face. The hard tissue (teeth and bone) support the soft tissue ( lips, cheeks and chin) to give a well balanced profile and facial appearance. Too often after orthodontic treatment we see teeth that perfectly fit together, but a lower jaw and/or chin that is too short causing a severe convex profile, or flattened lips due to incorrect retraction of front teeth, or an upper jaw that is vertically too long showing a lot of gum tissue when smiling.
The two most common reasons for malocclusion are teeth that have moved into the wrong position in the bony arch ( dental) or abnormal relationships between upper and lower jaws (skeletal) , or combinations of both. Correctly diagnosing and treating the reason for malocclusion is very important to maintain support of the soft tissue. In certain cases where the skeletal discrepancy is small , attempts can be made to treat the malocclusion with pure tooth movement. This is called dental camouflage.
If however there is a huge skeletal discrepancy, a combination of orthodontic treatment and orthognatic surgery should be used to ensure a desirable result with long-term stability. Orthognatic surgery should only be considered to correct malocclusions, and not for pure cosmetic change. (an exception is chin reduction or advancement to improve profile).
Extractions should only be considered if there is a lack of space in the dental arch to accommodate the teeth present in the correct position and angulation. Most common reasons for extraction are:
- Bimaxillary protrusion (front teeth are angled severely forward with all back teeth in contact on a good arch form and width)
- Macrodontia (big teeth on relative small bony arches)
- Mesial drift of posterior teeth (back teeth moved forward taking up space of pre-molars or canines. There will be an impacted or blocked out tooth elsewhere in the dental arch)